Two things come to mind when I think of Shaquille O’Neal. First, he was one of the most dominant centers in NBA history. Second, IcyHot “saved” him from pain. Well, that is what he would have us believe.
There was a period when every other commercial break on ESPN included Shaq telling me how these magic patches use “icy to dull the pain and hot to relax it away™.” IcyHot was hardly the first company to take advantage of the pain-relieving effects of hot and cold modalities.
I don’t have an exact date, but it is safe to assume people have been strapping on homemade icepacks for longer than TV commercials have been around. Whether it is a bag of frozen peas or a homemade ice bath, cold remedies have been used to treat pain long before research explored their true effectiveness.
If you step into an athletic training room or a physical therapy clinic, you won’t have to search long to find the freezer with the cold packs. Each one I have worked in has at least one.
When I worked with the Virginia Tech track and field team, every sprinter jumped in an ice bath after practices and meets. Pitchers encase their shoulders in ice packs that could double as body armor. Post-operative ACL-repair patients strap on expensive contraptions that pump cold water through a sleeve that surrounds their swollen knees.
Cryotherapy — the fancy medical term for treatment with cold therapy — is embedded in the rehab and fitness communities.
Should it be?
What does cryotherapy do?
I am getting ahead of myself. Before asking what it does, let’s review what is commonly taught in physical therapy and medical school
The premise of cryotherapy is simple. Cold decreases pain and aids recovery by limiting excessive inflammation. Let’s look at each of those effects separately.
Research shows cold packs may provide a meaningful reduction in pain but the effect is short-lasting. This doesn’t mean pain relief is useless. It simply means a cold pack will not eliminate pain.
The American College of Physicians 2017 low back pain Clinical Practice Guidelines concluded that the evidence was too sparse and inconclusive to recommend cold packs. As a physical therapist, I do not use cold packs in the clinic. I can have a more meaningful impact on pain with movement and manual therapy. Also, slapping on a cold pack is not skilled care. You don’t need to pay someone with a doctorate to use cryotherapy.
Now for the bigger question. Does cryotherapy aid recovery by reducing excessive inflammation and damage?
The current state of the research shows ice may be more harmful than helpful regarding inflammation. That’s right. The research supports the opposite stance of conventional wisdom, which is why I no longer provide ice to my patients.
Allow me to explain further.
Inflammation is beneficial
Inflammation is a crucial process in our body. For injuries, inflammation is used to lay the groundwork for healing.
When someone suffers an injury, such as a strained hamstring, the body triggers the inflammatory process. Neutrophils and macrophages are called to the injury site to destroy bacteria and remove damaged tissue cells, respectively. Following the clean-up process, Insulin-like growth Factor (IGF-1) — an anabolic hormone — flows into the area to stimulate healing and repair.
Cryotherapy slows down this process. It may even lead to immature muscle fibers. But what about secondary damage caused by inflammation?
Our bodies are finely tuned machines that have a better understanding of what it needs than any physician or trainer. In fact, cryotherapy can cause secondary damage by limiting the inflammation process.
The other common justification of ice is to reduce swelling. Again, swelling is a natural part of the process. It is an accumulation of the waste byproducts from the inflammatory response. The lymphatic system is responsible for removing the waste. Since the lymphatic system does not have a powerful muscle like the heart to assist with drainage, it is a slow process, relying on the contraction of muscles. Since muscle contraction is often limited after an injury, compression and elevation are needed to assist with drainage.
But there is an important piece to remember. Healing is natural and shouldn’t be rushed.
Switching from RICE to PEACE & LOVE
RICE (rest, ice, compress, elevate) and the updated PRICE (add protection to the beginning) are part of traditional injury management 101. They should be abandoned.
Research doesn’t provide much support for this approach. Most studies show the addition of RICE does not enhance outcomes. The few studies that show improvement are comparing different types of cryotherapy protocols, such as cold-water immersion vs. intermittent ice pack application. The few studies comparing ice to no ice do not support the use of RICE to improve recovery. Some studies even show icing delays recovery.
Instead, appropriate load management — meaning allowing the injured part of the body to heal and by gradually increasing activity — will do the job. So, the “P” part is right, but if you take out the “I” the acronym falls apart.
The biggest misconception about pain is it should be avoided at all costs. It is one of the primary reasons we are in the midst of an opioid epidemic and chronic pain continues to worsen. Instead of confronting pain, we fear it and seek any means to avoid it.
Now, there are many conditions — cancer, rheumatoid arthritis, fibromyalgia — that can lead to chronic pain and are more complex than a hamstring tear or ankle sprain. However, pain caused by injuries is a natural and beneficial response. Acute pain is a signal that we should allow the injured tissue to heal. Inflammation sensitizes local nerves, increasing the ease at which pain is stimulated. That pain serves as a protective response.
The two worst responses to pain following an injury are complete inactivity and seeking any external means — medication and ice for example — to eliminate the pain. Athletes may need to miss a few games and gardeners may need to take a weekend off from weeding, but they do not need to rush to pain medication and ice. Instead, let the pain guide your activity level, understand the body will heal, and continue to live your life. Use the PEACE & LOVE principle instead of RICE or PRICE
P = Protect
Let pain guide you. Avoid heavy loading and restrict movement for a couple of days. Don’t become inactive, though.
E = Elevate
Not necessary but could provide some benefit if swelling is present.
A = Avoid anti-inflammatory modalities
For all of the reasons mentioned above. This includes ice and NSAIDs (e.g. Advil).
C = Compress
Like elevation, this can limit swelling. You may speed up the waste removal, allowing you to return to activity sooner.
E = Educate
This applies to healthcare providers. It includes educating on proper load management (see next point) and pain (see above). Education is the most powerful treatment at my disposal as a physical therapist.
L = Load (starts after the first few days)
Loading should follow the healing process. As the tissue strengthens, more load is tolerated. Immature muscle, ligaments, tendons, and bone require loading to strengthen. Inactivity will not restore tissue strength.
O = Optimism
Our emotions and expectations greatly influence our pain experience. The primary drivers of transitioning from acute to chronic pain are depression, anxiety, and fear of movement. No one likes being injured. But understand your body will recover if you take the right approach.
V = Vascularization
Early activity, particularly aerobic exercise, improves blood flow and assists with the healing process.
E = Exercise
Exercise is necessary to fully restore lost muscle, strength, and tissue integrity.
What about recovery from exercise?
So far, I have only talked about recovery from an injury. What about recovering from exercise?
Athletes often use cryotherapy after an athletic event, such as an ice bath after running or a sleeve of ice after pitching. The idea here is the cryotherapy will speed up recovery as inflammation is not desired. Anecdotally, many athletes swear by cryotherapy as a method to speed recovery and improve performance.
Again, let’s look at the research.
The evidence for using cryotherapy to reduce delayed onset muscle soreness (DOMS) is mixed, but it does appear to induce some reduction in pain perception. The research remains mixed when assessing performance in follow-up training sessions after cryotherapy.
The body is resilient and adaptive. Exercise, when structured appropriately — causes our bodies to build strength and endurance to better tolerate future stimuli. If you are struggling to recover between bouts of intense activity, the issue is some combination of training dosage, sleep, and nutrition, not the lack of ice. Research shows cryotherapy does not help elite athletes with recovery and performance.
Keep in mind, low-grade inflammation is ideal after exercise. It is necessary to stimulate the growth and strengthening of muscles, ligaments, and tendons. If we blunt that inflammation through the icing, we may delay recovery, not enhance it.
Take a long-term perspective
The use of ice can be attributed to passed down “common knowledge” and short-term goals. Whether you are suffering from a recent ankle sprain or just came out of ACL surgery, icing is not the answer. If swelling is the concern, which is common after surgery, appropriate activity, elevation, and compression will be more effective.
Icing can decrease pain, but the benefits do not outweigh the harm. Delayed healing will prolong the pain experience as well. If pain is a concern, you can use distraction (work, reading, TV, hanging out with friends, etc.) or massage for immediate relief. Good sleep, diet, and exercise habits will expedite the healing process, reducing inflammation naturally and decreasing pain sensitivity.
So, to come full circle, should you ice after an injury? According to the current state of research, you should not.